Gknowmix Test Request


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Client Details

Service Options

Please select a test type
Service Required?
Receive quote email:
Receive informed consent email:

Health Care Practitioner Information

Referring Health Professional email address
Referring Healthcare Practitioner
Contact Number
Participating HP Email Address
Copy to Participating HP
Participating HP Contact Number
Client Email Address
Client Title
Client First Name
Client Surname
Address
Post Code
Date of Birth
Age
Ethnicity
Gender
Client Contact Number
Gknowmix Reference
Family Number / Index (Office Use)
Specimen Identifier / Barcode

Consent

I hereby give consent to services requested, guarantee payment and verify that all information is correct
The laboratory is allowed to release the diagnostic codes to my medical aid if necessary
My genetic material and clinical information may be included in in a database for research, related to the services requested, without revealing my identity
After completion of the genetic test my genetic material should be handled as follows:
Date of Consent

Medical Aid Information

Medical aid
Plan Option
Member Number
Reference / Authorization No
ICD-10 Code
Medical Aid Motivation
Include Medical Aid Motivation in Quote

Indication for Testing

Previous genetic test(s) performed
Previous diagnosis of a hereditary condition
At risk due to a high prevalence of a medical condition in family
Need to identify the cause of certain condition(s)
Health Maintenance / Monitoring
Treatment Failure / Medication Side Effects
Extended testing indicated / performed
Research

Personal Medical Conditions

Age of OnsetMedication
Angina
Alzheimers Disease
Anaemia / iron deficiency
Arthritis / Osteoarthritis
Cardiomyopathy
Cardiovascular Disease
Chronic Fatigue
Chronic Inflammation
Chronic Periodontitis
Coronary Heart Disease (e.g.Angina, myocardial infarction)
Deep Vein Thrombosis
Dyslipidaemia
Familial Hypercholesterolaemia
Haemochromotosis / High Iron
High Cholesterol
Hypertension / High Blood Pressure
Hypothyroidism
Insulin Resistance
Ischaemic cerebrovascular disease
Metabolic Syndrome
Multiple Sclerosis
Myocardial infarction
Non-alcoholic fatty liver disease
Obesity / Overweight
Osteoporosis
Peripheral Vascular Disease
Polycystic ovary syndrome
Porphyria / Variegate porphyria
Pulmonary Embolus
Recurrent Pregnancy Loss / Infertility
Restless legs syndrome
Schizophrenia
Sleep Apnea
Stress / Anxiety / Depression
Stroke
Thrombosis
Transient Ischaemic Attack
Type II Diabetes / High blood sugar
Vascular Dementia
Cancer Type
Cancer type Other
Cancer subtype / mutation (e.g. ER, PR, HER2, Ki67/Blueprint)
Cancer recurrence - age(s)
Cancer metastasis - organ(s) affected
Other Condition 1
Other Condition 2
Other Condition 3
Other Condition 4
Other Condition 5

Family Medical Conditions

Age of OnsetFamily Relation
No family history due to adoption
Angina
Alzheimers Disease
Anaemia / iron deficiency
Arthritis / Osteoarthritis
Cardiomyopathy
Cardiovascular Disease
Chronic Fatigue
Chronic Inflammation
Chronic Periodontitis
Coronary Heart Disease Disease (e.g. Angina, myocardial infarction)
Deep Vein Thrombosis
Dyslipidaemia
Familial Hypercholesterolaemia
Haemochromotosis / High Iron
High Cholesterol
Hypertension / High Blood Pressure
Hypothyroidism
Insulin Resistance
Ischaemic cerebrovascular disease
Metabolic Syndrome
Multiple Sclerosis
Myocardial infarction
Non-alcoholic fatty liver disease
Obesity / Overweight
Osteoporosis
Peripheral Vascular Disease
Polycystic ovary syndrome
Porphyria / Variegate porphyria
Pulmonary Embolus
Recurrent Pregnancy Loss / Infertility
Restless legs syndrome
Schizophrenia
Sleep Apnea
Stress / Anxiety / Depression
Stroke
Thrombosis
Transient Ischaemic Attack
Type II Diabetes / High blood sugar
Vascular Dementia
Cancer Type
Cancer Type Other
Other family medical conditions 1
Other family medical conditions 2
Other family medical conditions 3
Other family medical conditions 4
Other family medical conditions 5

Medical Data

Please use a decimal point (.) not a comma when capturing medical data

Please use a decimal point (.) not a comma when capturing medical data

Total cholesterol (TC) mmol/L
LDL-cholesterol (LDLC) mmol/L
HDL-cholesterol (HDL) mmol/L
Triglycerides, fasting mmol/L
TC:HDL Ratio
Lipoprotein (a) (Lp (a)) nmol/l
Homocysteine (Hcy) umol/L
C-reactive protein (CRP) mg/L
High-sensitivity C-reactive protein (CRP) mg/L
Glucose, fasting mmol/L
Glycosylated hemoglobin (HbA1c) %
Serum ferritin ng/mL
Serum iron umol/L
Transferrin g/L (divide µmol/L by 12.6 to convert to g/L)
Transferrin saturation %
25-OH Vitamin D ng/ml (divide by 2.5 to convert nmol/L to ng/ml)
Bone mineral density
Other pathology test results
Blood pressure – Systolic mmHg
Blood pressure – Diastolic mmHg

Lifestyle & Nutrition Assessment

Weight kg
Height m
Body mass index (BMI) kg/m^2
Waist circumference cm
Hip circumference cm
Waist to Hip Ratio Waist/Hip
Contraceptive pill
If yes or previous, provide details:
Hormone replacement therapy
Pregnant
Number of pregnancies
Number of children
Number of weekly Physical Activities > 30 Minutes
DAYTIME ACTIVITY
SMOKER
Alcohol Intake

Nutrition Assessment

Dietary Questionnaire

Hamburgers, Pizza
Red Meat e.g. Beef, Lamb, Mutton
Fried Chicken/ Cooked Chicken with skin
Hot Dogs / Sausages
Salad dressing (excluding 'Lite' versions)
Butter and Margarine (excluding pro-active versions)
Fried eggs (excludes cooking, boiling and baking)
Full cream milk and dairy products (fresh, sour or powdered)
Fried hot potato chips, potato crisps, corn chips, popcorn
Biscuits, cake, cookies, pastries
All Legumes (beans, peas, lentils)
Potatoes with skin
At least 5 portions fruits and vegetables (per day)
Whole grain breads. cereals (low GI wheat, oats)
Broccoli, cauliflower, mushrooms
Turnips, artichokes, asparagus
Avocado, spinach
Oranges, grapefruits (pure fruit versions)
Organ meats (e.g. liver, kidney, giblets)
Fizzy drinks, tea/coffee with sugar
Food Intolerance or Allergy
Food supplements taken daily
Food supplements taken occasionally
Food preferences such as vegetarian or vegan
Iron / vitamin B12 injections
Blood Donor
Prolonged exposure to environmental toxins (e.g. agricultural pesticides, occupational solvents)

Medication side effects/failure?

Cholesterol-lowering statins (e.g. muscle pains)
Anti-depressants (e.g. weight gain)
Immunomodulating drugs (e.g. depression) ?
Anti-retrovirals (e.g. weight gain, dyslipidaemia)
Aromatase inhibitors (e.g. muscular skeletal inflammation, bone density reduction/loss)
Tamoxifen (e.g. deep vein thrombosis)
Other, (e.g. tamoxifen resistance)
Which side effects were a problem for compliance?

Genetic Testing

Patient Deceased
APOE4 T > C
APOE2 C > T
MTHFR 677 C > T
MTHFR 1298 A > C
FV Leiden G > A
F2 20210 G > A
PAI-1 / SERPINE1 4G / 5G
HFE C282Y G > A
HFE H36D C > G
TMPRSS6 C > T
FTO T > A
GNB3
ADRB2 C > G
FABP2 G > A
PPAR gamma C > G
Interleukin-6
TNF alpha G > A
GSTT1 NULL
GSTM1 NULL
MnSOD T > C
COMT G > A
CYP2D6 - 2549 del A
CYP2D6*4 G > A
Research Number